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<meta name="description" content="宅在家里，学习不能停。继续。 第二节 咬合治疗1.概述a.咬合负担致应力集中b.应力集中颈部破坏釉柱c.配合生物腐蚀牙齿降解d.釉质破坏加速NCCL和CDH2.咬合不平衡a.对颌牙过萌b.牙齿移位3.肌肉适应早接触牙齿，肌肉收缩异常。引起磨耗。4.咬合治疗的适应症a.微创伤性咬合(cdh，牙周骨丧失，内部碎裂等)b.TMDS的肌肉疾病(由于疼痛或副功能就诊的)c.tmj治疗作为临床治疗的补充(正畸">
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          <h1 class="post-title" itemprop="name headline">楔状缺损的咬合治疗</h1>
        

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<p>第二节 咬合治疗<br>1.概述<br>a.咬合负担致应力集中<br>b.应力集中颈部破坏釉柱<br>c.配合生物腐蚀牙齿降解<br>d.釉质破坏加速NCCL和CDH<br>2.咬合不平衡<br>a.对颌牙过萌<br>b.牙齿移位<br>3.肌肉适应<br>早接触牙齿，肌肉收缩异常。引起磨耗。<br>4.咬合治疗的适应症<br>a.微创伤性咬合(cdh，牙周骨丧失，内部碎裂等)<br>b.TMDS的肌肉疾病(由于疼痛或副功能就诊的)<br>c.tmj治疗作为临床治疗的补充(正畸、修复、手术)<br>5.咬合治疗的记录介质和记录技术<br>a.咬合纸<br>优点:低成本，易获得，一次性，可视化分析<br>缺点:液体污染，颊舌组织推移(用夹持架)<br>b.咬合记录蜡<br>优点:低成本，发现初始咬合点，标记咬合调整对应的咬合面，可视化分析。<br>缺点:使用咬合纸受限，先用咬合纸再用咬合蜡。<br>c.牙合架<br>咬合评估和确定治疗计划相对昂贵的手段<br>1)为何上颌架?<br>①医生直视下分析咬合关系(咬合治疗必要步骤)<br>②追踪记录合面磨耗进展及造成nccl的慢性微创伤生物腐蚀的进展。<br>③牙齿移位时(尤其远中移位时)有助于发现tmj的病理变化。<br>④复杂正畸和修复治疗计划制定的必要步骤。<br>⑤制作牙合垫的必要步骤。<br>⑥医患沟通的可视化工具<br>2)上牙合架的注意事项<br>①取印模保证印模的精确性<br>②上颌架前应取得准确的面弓记录<br>③确定上颌牙弓相对水平参考平面的位置关系。<br>④下颌模型上颌架前应制取精确的上下颌间记录<br>⑤制取准确的下颌侧方运动记录并转移到牙合架上。<br>⑥根据自己的需要配置全可调或半可调<br>d.T-scan数字化分析<br>获取患者咀嚼模式中客观的咀嚼力大小和时间。<br>间接获得肌肉收缩的信号。<br>为咬合治疗获得准确信息。<br>6.咬合治疗的选择<br>a.咬合治疗的分类<br>1)加法——增加牙齿高度<br>方法:<br>建立尖牙引导或前牙引导。<br>侧方咬合时达到后牙快速分离。<br>步骤:<br>①酸蚀上颌尖牙、上颌切牙舌侧面或下颌尖牙切嵴。<br>②CAD/CAM修复技术<br>③或者技工室制作尖牙瓷修复体或氧化锆修复体。<br>2)减法——调合降低高度<br>方法:<br>椅旁采用高速或低速手机降低垂直高度<br>或调改侧方咬合接触点。<br>微量调整(&lt;0.1mm)<br>微量调整(&gt;0.1mm)时早接触可能与修复体或充填体有关。<br>步骤:<br>①面弓转移上颌架<br>②采取正中侧方咬合记录<br>③模型上检查口内校对<br>④口内调磨<br>b.咬合治疗的选择<br>7.选择性调颌<br>a.概述<br>①定义<br>调合:对某颗牙或某处咬合接触点进行减法治疗而不涉及整个牙列。<br>选择性调牙合:对咬合类疾病有造诣的医生通过局部调合解决特定的病理过程。<br>②适应症<br>无需改变牙齿骨支持(垂直距离)<br>无需改变牙齿的位置<br>无需修复牙体缺损的病例<br>修复NCCL前常规的辅助治疗<br>③遵守原则<br>消除导致正中关系(CR,RP)与最大牙尖交错位(MIP)不一致的接触位。(远端游离的基牙修复要注意非正中咬合，否则可能牙齿移位，食物嵌塞。)<br>改变牙齿受力方向使其平行于牙长轴。<br>避免改变功能尖高度(避免改变垂直距离)<br>修整后牙侧方咬合接触点(去除阻碍侧方和前伸运动的后牙接触点)<br>获得正中关系牙合(CO)的稳定性避免功能尖的进一步改变。<br>④要求<br>最小量调整<br>改善咀嚼系统的健康<br>避免带来伤害<br>先在牙合架上调牙合并记录<br>⑤步骤<br>CO调合<br>侧方咬合早接触点调牙合<br>前伸咬合调牙合<br>b.正中关系的调牙合<br>①术前准备<br>在牙合架上记录正中关系<br>②主要目的<br>确定使下颌偏离正中关系的初始咬合点<br>③主要方法<br>使用咬合纸或咬合蜡来寻找<br>④校对方法<br>在牙合架上重现口内的早接触点<br>⑤终极目标<br>正中关系与最大牙尖交错位一致<br>⑥模型调整并记录<br>记录牙位牙尖及存在早接触点的牙尖斜面。<br>注意应避免对石膏模型进行大量调整避免口内牙本质暴露。<br>⑦基于早接触点类型确定选择性调牙合的方法<br>早接触点使下颌偏斜远离中线:<br>        干扰点在功能尖功能面之间。<br>        调磨最接近牙尖顶点的点接近尖顶。<br>        未解除调整对颌牙合面。使对颌咬合点接近窝沟底。<br>早接触点使下颌偏斜朝向中线:<br>        干扰点在功能尖(非功能斜面)非功能尖(功能斜面)之间。<br>        先调磨功能尖的非功能斜面。使接触点接近尖顶。<br>        未解除，调非功能尖的功能斜面。<br>早接触点使下颌偏斜向前:<br>        干扰点在上颌功能尖近中斜面牙尖嵴与下颌功能尖远中斜面或牙尖嵴之间。<br>         同时调磨上下颌。<br>早接触点，下颌无偏斜:<br>        干扰点功能尖顶与对颌牙合面窝/边缘嵴之间。<br>        或在功能尖与对颌功能斜面的平台之间。<br>        若功能尖存在工作侧干扰应调磨功能尖。<br>        若功能尖不存在工作侧干扰应调磨扩大对颌牙合面窝或平台以适应该功能尖。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/014/01.png"><br>CR和RP位与MIP位一致后有未接触的牙齿，应考虑加法。<br>c.侧方牙合的调牙合<br>①术前准备<br>首先确认正中位与最大牙尖交错位一致<br>②术前观察<br>确定患者是尖牙保护牙合还是组牙功能牙合。<br>③使用器材<br>咬合纸<br>④终极目标<br>尖牙保护牙合<br>有尖牙参与组牙功能牙合。<br>⑤特殊情况<br>扭转、移位、缺损等先处理。<br>⑥调磨方法<br>尖牙保护牙合<br>工作侧调磨非功能尖功能面<br>平衡侧调磨影响工作侧tmj侧移的任何点。<br>组牙功能牙合<br>工作侧必须有尖牙的参与<br>平衡侧调磨影响工作侧tmj侧移的任何点。<br>d.前伸咬合调牙合<br>①术前准备<br>正中侧方调牙合完毕。<br>②术前观察<br>前伸时前牙是否多点接触后牙是否分离<br>③使用器材<br>咬合纸<br>④终极目标<br>前牙多点接触，后牙分离。<br>⑤后牙干扰的影响<br>影响tmj的生理性前移<br>产生干扰的后牙承受剪切力。<br>釉质牙本质内部碎裂修复体脱落。</p>
<p>个人总结:咬合问题是形成NCCL和CDH的一个原因，因此咬合调整是一个治疗方法。使用的设备器材有咬合纸，牙合架，咬合记录蜡等。咬合调整的方法有加法和减法。加法是增加牙齿高度，建立尖牙引导或前牙引导，使侧方咬合时后牙分离。用牙合贴面等方法。减法主要是调合。顺序是正中牙合，侧方牙合，前伸牙合。正中调牙合目标是使正中关系与最大牙尖交错位一致。侧方调合目标是建立尖牙保护牙合或组牙功能牙合。前伸调牙合的目标是前伸咬合时前牙多点接触，后牙分离。</p>
<p>我发文章的四个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的博客园博客地址： <a target="_blank" rel="noopener" href="https://www.cnblogs.com/zwdnet/">https://www.cnblogs.com/zwdnet/</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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